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psychological condition to the FAA and only one of the fourteen pilots had reported the psychotropic
medication.
In 1987 in Australia, the Civil Aviation Safety Authority (CASA) began allowing aviation personnel who
had been depressed to operate once they had been effectively treated and had become stable with the use
of antidepressant medications. The policy had become somewhat liberal with the allowance of use of
most medication groups including monoamine oxidase inhibitors (MAOI) and tricyclic antidepressants
(TCA). There were no reported adverse outcomes related to this policy but in 2003 a more restrictive
approach was introduced with increased surveillance and limitation to specific medications 17. A study,
ICAO Preliminary Unedited Version — November 2009 III-9A2-2
published in August 2007, focused on safety outcomes such as accidents and incidents in 481 certificate
holders over a ten year period and found no evidence of adverse outcomes related to allowing pilots to fly
on antidepressant medication, provided specific criteria were met 14
.
In Canada, pilots on maintenance therapy are allowed to fly “with or as co-pilots” under an aeromedically
supervised treatment protocol in which pilots are followed prospectively 18
.
The AsMA position paper 12 points out that several factors must be considered in relation to safety should
certificate holders be allowed to operate whilst using antidepressant medications. Firstly, it is important to
establish the diagnosis. Selective serotonin reuptake inhibitors (SSRIs) are used to treat not just
depression, but some other aeromedically significant illnesses such as obsessive compulsive disorder and
panic disorder. Secondly, patients generally have their adverse reactions to SSRIs early in treatment;
these side effects usually diminish as the patient becomes physiologically accustomed to the medication.
Thirdly, the newer SSRIs have fewer side effects than the older antidepressants because they are designed
to act only on receptors in specific areas of the brain.
Some of these medications are sedating and some are not, thus offering a therapeutic choice in treating
depressed patients who show psychomotor agitation or retardation. Fewer side effects generally result in
improved aeromedical safety. However, successful treatment of depression is a dynamic and complex
process involving more than just writing a prescription and the SSRIs can have some aeromedically
significant side effects and withdrawal effects that are of little importance in ordinary clinical practice 12
.
Finally, an important aspect to consider is that a diagnosis of depression often carries with it significant
social stigma and in many societies it is common that symptoms of depression are not discussed openly
with either colleagues or members of the medical profession. Aeromedical policies that place an absolute
prohibition on operating after a diagnosis of depression may also make it less likely that an aviator or air
traffic controller will seek treatment or declare their illness to the Licensing Authority.
3. Guidance
3.1 The assessment of pilot and air traffic controller applicants with depression
Depressive mood disorders (ICD-10: Depressive episode; DSM-IV-TR: Major Depressive Disorder) are
common disorders which present with depressed mood, reduced energy, impaired concentration and
memory, loss of interest in surroundings, slowed cerebration, difficulty in making decisions, alteration of
appetite and sleep, guilt feelings, and low self esteem. Suicide is common; the incidence varies with
cultural background, but may approach 20 per cent per depressive episode.
The illness is usually of insidious onset and persists for many months when not treated adequately.
Depression may be accompanied by a number of somatic symptoms. There may be diurnal variation in
the symptoms, and many persons with depression may have some good days in between. It is not unusual
for sufferers to try to modify their symptoms (especially the dysphoria and insomnia) by the use of
alcohol and prescribed medications or illicit drugs.
Depression leads to subtle (and sometimes overt) incapacitation, mainly due to the decreased ability to
concentrate, as well as to distractibility and indecision, which are frequent features of the illness. It is
these symptoms, along with the risk of suicide, which make a depressed individual unsuitable to work in
the aviation environment. Because the symptoms wax and wane during a depressive episode, there may
be days when the individual is relatively well and may appear to be fit to fly. However, impaired
concentration and lack of cognitive agility are always more or less present and may interfere with the
ability to integrate the multiple sensory inputs required to make decisions in an emergency situation.
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Manual of Civil Aviation Medicine 2(19)
